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NEUROSURGICAL ANESTHESIA

Intraoperative Localization of an Epileptogenic Focus with Alfentanil and Fentanyl

Pirjo H. Manninen, MD, FRCPC^*, Sharon J. Burke, MBBS, FRCA^*, Richard Wennberg, MD, FRCPC, Andres M. Lozano, MD, PhD, FRCSC, and Hossam El Beheiry, MBBCH, FRCPC^*

Departments of *Anaesthesia, Neurology, and Neurosurgery, University of Toronto, The Toronto Hospital, Western Division, Toronto, Ontario, Canada

Address correspondence and reprint requests to Pirjo H. Manninen, MD, Department of Anaesthesia, The Toronto Hospital, Western Division, 399 Bathurst St., Toronto, Ontario, Canada M5T 2S8.

We evaluated the effectiveness of alfentanil and fentanyl in stimulating epileptogenic activity during surgery for intractable temporal lobe epilepsy under general anesthesia. Ten patients received a standardized anesthetic induction with IV fentanyl 5 µg/kg, propofol 3–5 mg/kg, and atracurium 0.5 mg/kg. Maintenance was with isoflurane, 70% N₂O/30% O₂, and an atracurium infusion. After dural opening, droperidol 0.02 mg/kg was administered IV. Both inhaled anesthetics were discontinued and verified to be at 0 end-tidal concentration before the study. Baseline electrocorticography over the surface of the temporal lobe and depth electrode recordings in the amygdala and hippocampus were obtained, followed by 10 min of recording before and after the IV administration of both alfentanil 50 µg/kg and fentanyl 10 µg/kg. Any changes in cardiovascular variables were documented. The number of interictal epileptiform spikes at the most active site for each patient was tabulated before and after the administration of each drug. Both alfentanil and fentanyl induced an increase in spike activity in all patients. Alfentanil was more potent, increasing the median number of spikes per epoch from 18 to 58, compared with fentanyl (20 to 42 spikes) (P < 0.05). Alfentanil had a shorter duration of action (4.9 ± 1.3 min) compared with fentanyl (8.5 ± 2 min) (P < 0.009). In nine patients, the most active site was the hippocampus or amygdala. There was a decrease in mean blood pressure, but only after the administration of alfentanil (P < 0.05). Two patients had electrographic evidence of seizure activity. These opioids can be used to assist in the localization of the epileptogenic focus during surgery.

Implications: Both alfentanil and fentanyl activate epileptiform activity in patients with temporal lobe epilepsy. These opioids can be used to assist in the localization of the epileptogenic focus during surgery.

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